Wednesday, September 30, 2009

Super Glue Eyelid

This little girl accidentally got Super Glue onto her eyelid. She came to the doctor without pain and she was able to move the eyeball under the lid but could not open it.

Her doctor in Decatur, Ala gently irrigated the eye area with normal saline and applied antibiotic ointment and a gauze patch over the eye area but the lid remained stuck together. The next day he was able to gently pull the lid open.

If you should ever glue parts of your body together with Super Glue (cyanoacrylate), the treatment is easy. Acetone, the ingredient found in nail polish remover will dissolve Super Glue. A Q-tip with acetone, gently applied to the area, will dissolve the bond without damaging the skin. Don't pull the skin apart, but gently roll or peel it.

If Super Glue gets in the eyeball, the eye protein will disassociate from it over time. A warm sodium bicarbonate solution eyewash will help remove the adhesive.

Photo/story credit: Consultant

Tuesday, September 29, 2009

In the Patient's Interest

I spent the entire day in meetings today. One would think that is a boring or unproductive way for a physician to spend time, however these meetings made me proud to be a doctor and proud of my colleagues in medicine.

The morning was spent with nurses, respiratory therapists and quality experts who came together to celebrate success with patient safety and quality initiatives that have saved at least 151 patient lives. These caregivers from a number of different hospitals, have worked together for 3 years on on reducing deep venous thrombosis, ventilator acquired pneumonia, skin ulcers and sepsis.

Medicine is a team sport and it is only when the team is humming and everyone is working together that patients can have good outcomes. Hospital errors, medication errors, poor communication between doctors and nurses are prevented by adherence to protocols that everyone follows. It takes laser focus, measuring outcomes and a great deal of hard work to ensure everyone is pulling together in a hospital. The fact that these bedside nurses take the time to work on error reduction and patient safety is really amazing. Have you seen how hard nurses work? My hat is off to these dedicated care-givers.

Tonight I met with physician leaders who are spending their precious "after work" time to discuss how to improve patient care in their communities. We discussed how to seamlessly transfer patients from one hospital to another and how to make sure physicians get continuing medical education to keep their skills on the cutting edge.

We talked about the decline in primary care physicians in most communities and how to help them survive in hostile practice environments when it seems none of the "health care reform" ideas will address the shortage.

While health care reform is being discussed in Washington, doctors and nurses are quietly going about their business providing the best health care we can. I am proud to be associated with these care-givers who are spending enormous amounts of time and energy to improve the system and make the patient the first concern.

Sunday, September 27, 2009

Shameless Corporation of the Week Award

Each week EverythingHealth will bestow its "Shameless Corporation of the Week Award" to a deserving health insurance company. Somehow I do not think it will be hard to find a recipient each week.

Today's award goes to: Blue Shield of California HMO.

When Rosalinda Miran-Ramirez awoke with bleeding from her left breast nipple she awakened her husband and had him drive her to the local emergency department. The doctors found a tumor that they thought was breast cancer but a biopsy later proved it to be benign.

Blue Shield denied the emergency room visit and she received the total charge from the emergency visit: $2791.00. Blue Shield reviewed the case and determined that Miran-Ramirez "reasonably should have known that an emergency did not exist." When she appealed, she was denied again and told she was not in "any acute distress."

The Shameless Award for this week goes to Blue Shield of California. Since when isn't a blood soaked shirt and a bleeding breast cause for insurance coverage?

Saturday, September 26, 2009

Fertility Clinic Mistake Ends Up Good

It made me feel good to read that a mistake by a fertility clinic in Michigan ended with a happy ending. The biologic parents created an in-vitro embryo that was accidentally implanted into another woman at the clinic. A few days later the clinic notified Carolyn Savage that she was carrying Paul and Shannon Morell's embryo. She never considered terminating the pregnancy or trying to fight for custody.

A 5lb 3oz healthy baby boy was born Thursday to Carolyn Savave and the Morells now have a new baby. They call Carolyn Savage their "guardian angel." This is how you turn a lemon into lemonade. If we can keep the lawyers away...this is an example how how to go with the flow and live life to the fullest.

Congratulations to to very cool families.

Friday, September 25, 2009

Spanking Linked to Lower I.Q.

A new study funded by the National Institute of Mental Health has found that children who are spanked end up with a lower I.Q. than children who are not spanked. The researchers looked at 32 nations (including the U.S.) that used corporal punishment and compared the I.Q. between children.

They found that the children who were spanked the most fell behind I.Q. development scores. But even children who were spanked a "little" were behind those who did not receive corporal punishment.

"The longitudinal part of our study showed that children who were spanked the most fell behind the average IQ development curve, and those who were never spanked advanced ahead of the average", said Dr. Murray Straus, study lead.

The IQs of children aged 2 to 4 years who were not spanked were 5 points higher 4 years later than the IQs of those who were spanked. The IQs of children aged 5 to 9 years who were not spanked were 2.8 points higher 4 years later than the IQs of children the same age who were spanked.

The analysis showed a lower national average IQ in nations where spanking was more prevalent. Dr. Straus said that the strongest link between corporal punishment and IQ was for those whose parents continued to use corporal punishment even when subjects were teenagers.

Spanking is stressful for a child and frequent spanking leads to chronic stress and even post-traumatic stress syndrome. These symptoms can lead to lower I.Q. Is it a cause-effect relationship? No-one knows for sure, but health educators have shown the ineffectiveness of corporal punishment before, so educating parents in positive and non-punitive forms of behavior modification look like the answer.

Wednesday, September 23, 2009

Seborrheic Keratosis, Common and Benign

Seborrheic Keratosis are common and they are raised dark papules that appear on the skin as a person ages. The are usually located on the face, chest, back or shoulders and can be rough to the touch. Some people develop quite a few and others are scattered.

Seborrheic Keratosis are skin tumors that are benign. The cause is unknown but they seldom appear before age 40. They are mainly a cosmetic issue and can be removed with simple surgery or cryotherapy (freezing).

Sometimes they can get rubbed by clothing and become irritated. They do not transform into cancer. Just another birthday present from Mother Nature!

Monday, September 21, 2009

Health Insurance Denied

One difficult part about being a doctor is that I am part of a horrible, greedy, uncaring industry that I cannot influence. Ah, such strong words for American medicine, you say? Well, I have encountered yet another patient who is denied health insurance for underwriting reasons that are just plain unfair.

Maryanne has run out of COBRA, the temporary continuation of health insurance that is guaranteed when a person loses their job. It only lasts 18 months and, in case you didn't know it...we are in a hell of a recession and there are a lot of people who are unemployed.

Maryanne, age 41, was turned down by Blue Shield of California after submitting all of her health records because she (and I quote) "did not meet the underwriting acceptance criteria:
  • Migraines treated with Imitrex, Aleve, seen in emergency department once 2009
  • Thyroid adenoma treated with Synthroid
  • Deaf "
This is pretty outrageous. One migraine headache that required an over- the- counter pain killer and a recognized pill that works for migraine is hardly a rare health condition. Some 30 million Americans have migraine headaches.

She is deaf since childhood and functions completely normally by lip reading. Of course, being profoundly deaf does affect her ability to get just any old job in this economy, doesn't it?

She does have a thyroid enlargement that will likely need further investigation. These are easy to work up but, without insurance, the cost can be exorbitant and probably more than an unemployed person can comfortably pay.

Another one has joined the 47 million uninsured. There is no safety net for Maryanne or millions of others who are living with the anxiety of being uninsured.

Saturday, September 19, 2009

The Perfect Dad

hat tip: Happy Hospitalist

Cheaper, Better and Fairer Health Care

I heard an interview with T.R.Reid and can't wait to read his book The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care. He traveled the world and compared how developed countries manage health care. He makes the point that all other developed countries have universal coverage. No-one is left out.

He found four basic systems (some named after their founders):

The Beveridge Model
: Health care is provided and financed by the government through tax payments, just like the police force or the public library. Some clinics, hospitals and doctors are government employees (like the Veterans Administration in the U.S.), and some are private doctors who collect their fees from the government. The government is the sole payer and the patient never, ever gets a bill. Preventive care is exceptional because health care is paid from cradle to grave and keeping the population healthy is a priority of the government. There are no stockholders to pay so health care dollars are used solely on health.

(Great Britain, Spain, most of Scandinavia, New Zealand, Hong Kong, Cuba)

The Bismark Model: It uses an insurance system financed jointly by employers and employees through payroll deduction. There are about 240 different insurance funds in Germany but they have to cover everybody and they don't make a profit. There is tight regulation so government has much of the cost-control clout that the single-payer Beveridge Model provides. Doctors and hospitals are private and patients can choose any provider they want.

(Germany, France, Belgium, the Netherlands, Japan, Switzerland and some Latin America)

The National Health Insurance Model: This system uses independent providers but payment comes from a government-run insurance program that every citizen pays into. There is no profit, no marketing and no financial motive to deny claims so these insurance programs are cheaper and easier to administer. ( This runs like U.S. Medicare). National Health Insurance plans control costs by limiting the medical services they will pay for.

(Canada, Taiwan, South Korea)

The Out of Pocket Model: In all of the other developed countries everyone is covered. The rest of the world (including 47 million Americans) are too poor and too disorganized to provide health care. If you don't have the money to see a doctor, you do without and get sicker or die. That's it...survival of the financial fittest.

The United States is unlike every other country because it maintains many separate systems for different classes of people. We have parts of every model but we are the only developed country that allows investor profits to dictate our health care. We are the only developed country that does not focus on primary care.

Tuesday, September 15, 2009

What's Up With Flu?

The messages from the Centers for Disease Control (CDC) and the American College of Physicians (ACP) this year are the same...get your flu shot. They are talking about the garden variety flu that hits every year in the fall and causes 36,000 deaths. Flu shots can spare people from suffering serious illness and saves thousands of dollars in health care costs. Here is who should get seasonal flu vaccine:
- Adults 50 or older.
- Residents of long term care facilities housing persons with chronic medical conditions.
- Anyone who has a serious long-term health problem with heart disease; lung disease; asthma; kidney disease; diabetes; or anemia and other blood disorders.
- Anyone whose immune system is weakened because of HIV/AIDS or other diseases that affect the immune system; long-term treatment with drugs such as steroids; or cancer treatment with x-rays or drugs.
- Women who will be past the third month of pregnancy during flu season.
- Physicians, nurses, health care workers.
- Family members and anyone else coming in close contact with people at risk of flu.
- Children between ages 6 months and 18 years, unless they have a serious egg allergy.

What about H1N1 (we call it "Heiny") flu? The vaccine is still being developed and tested. When it does become available, the following five target groups should be immunized:
- Pregnant women
- Persons who live with or provide care for infants less than 6 months old
- Health care and emergency medical services personnel
- Persons aged 6 months to 24 years old
- Persons aged 25 to 64 years who have medical conditions that put them at higher risk for flu-related complications.

Note that the lists are different. Certain risk groups (pregnant women and babies) suffer more serious complications from H1N1. Also the recommendations leave out older people because this type of flu has passed this way before and people over 50 probably still have some natural immunity.

Seasonal flu shots are now available. H1N1 vaccines should appear in November.

Monday, September 14, 2009

American Values and Health Care

I read a good post from NYT about Health Care Reform and 'American Values' and it got me a thinkin'...just what are American Values when it comes to health care? Usually I get a little anxious when I see "American Values" in a sentence, because what usually follows is something about rugged individuality, pulling oneself up by bootstraps, getting the damn government out of our lives and those damn immigrants and welfare mothers who won't work and want to live off others.

But I have listened to about ten thousand patients over the past 25 years, and I have a good idea of what these Americans want for health care. They are the silent majority...the people who work, study, raise their kids and seldom call into a radio talk show. They don't have time to go to town hall meetings and shout slogans.

They range from age 17 to 101 and most of them are middle class. They come in all races...Asian, Black, White, Pacific Islander and mixes of all.

Some are wealthy enough to have multiple homes and private planes.
Some are uninsured and watch their health care spending very closely. Most were thrilled to get Medicare and I've never heard a complaint from a Medicare patient.

Here is my list of what these Americans think about Health Care:
  • They do agree that everyone should be covered for basic health care and would pay higher taxes if they could believe that there would not be fraud and waste. (The recent banking meltdown has destroyed all confidence that government can regulate or be independent from special interests)
  • They want choice of physicians and hospitals
  • They are sick of insurance companies and all feel like they have been screwed in one way or another. They are shocked at how little insurance companies pay toward the doctor visit and the way those fees are discounted.
  • They are technocentric and want tests, imaging, referrals and think "more is better" when it comes to health care. They think tests are cures. Because of the perverse incentives, the "more is better" philosophy benefits doctors and hospitals, but not necessarily patients.
  • They fear losing insurance if they have it.
  • They are confused about the current reform debate and mostly fear losing whatever coverage they now have, because they know how impossible it is to get by without any coverage at all.
There are no such thing as "American Values" because we are a diverse group of people. But we all have certain things in common. We want to be healthy. We don't want to be screwed by anyone (big business or the government).

We want to be able to manage our own health care but we don't want to have to decide between numerous health plans every year with pages of information that cannot be understood. We are tired of not knowing where all the $trillions really are being spent.

We want to know the price of a service up front, and we want a trusted physician to help us decide if that is how our money should be spent. We want smart, committed physicians to know us, and not hurt us.

Sounds American to me.

Sunday, September 13, 2009

Geographic tongue

Geographic tongue is also known as benign migratory glossitis. The surface epithelium of the tongue has transient atrophy of the papillae and this causes these shiny patches. Sometimes it is caused by stress or spicy foods. Occasionally patients notice tongue irritation but many patients have no symptoms and just notice the unusual appearance.

Physicians will ask questions about dermatitis, diabetes, anemia and other conditions but once those have been ruled out, no therapy other than reassurance is necessary

(photo credit to consultant live)

Friday, September 11, 2009

Girls Suffer Worse Effects From Bullies

We all know that there can be long term mental health consequences for kids who are victims of bullies. A new study reported in the Archives of General Psychiatry showed that girls who are bullied in grade school suffer more psychiatric disturbance than boys. This is the first study that examined late adolescence or adult outcomes of childhood bullying in both boys and girls, and it found the long term effects of bullying were worse in the girls.

The researchers defined bullying as "an aggressive act embodying an imbalance of power in which the victims cannot defend themselves accompanied by an element of repetition." They found that more boys were bullies themselves, and more boys than girls were bullied. Very few girls were frequent bullies or bully-victims.

Despite the fact that girls were less bullied in early grade school, they were the ones who often had severe after effects. Frequent victim girls used more psychiatric medication, antipsychotics, antidepressants or anxiolytics in later life.

Childhood bullying is not "part of growing up". It is interpersonal violence and the negative effects do not disappear with time. Enlightened educators have a "no bully" policy and these acts are nipped in the bud. It is never OK to allow bullying, and both the perpetrator and the victim can suffer later consequences in life.

Wednesday, September 9, 2009

Dream Hospital

I love the sliding baby and the smoking father. The X-ray tech is unfortunately dead now since he wore no protective shield for the high tech $25,000 machine . And who wouldn't want the pneumatic tubes for sending records?

This hospital was $2 million. The cost of building a hospital in 2009 is $2.5 million per bed. And that doesn't include electronic medical records. Bring back the pneumatic tube.

(hat tip to Medical Jokes)

Monday, September 7, 2009

Just How Much Money Does Pfizer Have?

The Department of Justice has settled with Pfizer Pharmaceutical for $2.3 Billion. This is actually the fourth settlement with Pfizer,or one of its subsidiaries, since 2002 over illegal marketing, but those fines only totaled a paltry $513 million. I guess it is a good thing that the U.S. Government will be taking in some big money, rather than just paying it out in stimulus money, bailing out banks and escalating a war in Afghanistan. Way to go Justice Department! You are earning your keep.

These settlements were the result of whistleblowers who claimed Pfizer sent doctors on all-expense paid trips to resorts, gave out free massages and paid kickbacks to get them to prescribe drugs for off label uses.

I am glad the U.S. coffers will get a bit of $. What I am wondering, however, is just how much money does Pfizer have? The settlement had little effect on Pfizer's stock, which closed just 10¢ lower. Carol Levenson, research director at a corporate-bonds research service said, "And while $2.3 billion ain't chicken feed, it's affordable". Affordable? That tells me Pfizer is loaded and these types of fines are just annoyances.

Just how big is a billion dollars? A billion dollars is more than many total economies in third world countries. A billion minutes is roughly 1,900 years and the Roman Empire was in full swing. A billion hours ago we were living in the stone age. If we wanted to pay down a billion dollars of the US debt, paying one dollar a second, it would take 31 years, 259 days, 1 hour, 46 minutes and 40 seconds.

I will be pondering this the next time I remember that Medicare Part D (drug coverage for Medicare recipients) was passed with the caveat that there would be no contracting for better prices from Big Pharma. The government (all of us) will just pay the asking price. I will think of this when my patient's blood pressure shoots up or her arthritis pain is worse because she can't afford to pay over $100 a month for a single medication.

Just how much money does Pfizer have?
(a rhetorical question...I can look it up too)

Sunday, September 6, 2009

Vitamin D Is Essential

Vitamin D is essential for a number of functions in the body. It is essential for bone health, autoimmune diseases, cancer, heart disease, cognitive function and even pain control. Despite numerous studies that show low levels of Vitamin D are detrimental to overall health, deficiency seems to be pandemic. Before the last few years, physicians didn't even measure Vitamin D levels in the blood. We assumed if you got a bit of sunshine and weren't an elderly shut in, you were good.

Vitamin D comes in two forms, Vitamin D2 and Vitamin D3. Vitamin D3 is formed in the skin after exposure to Ultraviolet B radiation and from animal sources such as some fish. Vitamin D2 comes from plants (that have been exposed to sunlight) and foods are fortified with Vitamin D like milk, cheese, bread and juice.

Vitamin D goes through a complicated synthesis within the body to make a biologically active form. There are Vitamin D receptors in the intestine, prostate, colon and breast and most tissue and cells in the body. Vitamin D is one of the most potent regulators of cell growth in both normal and cancer cells.

I could go on and on but this should be just a "taste" of the importance of Vitamin D in maintaining health. Keep in mind that laboratory measurements of Vitamin D are not perfect, but if you aim for a goal of 35-40ng/ml, the Vitamin D status should be good.

Vitamin D deficiency can be treated with supplements that are relatively cheap to purchase. For healthy people, 1000-2000IU/day should bring low levels up to a normal range. For people who have severe deficiency (malabsorption, healing fractures, osteoporosis), larger doses may be necessary.

Ask your doctor to screen for Vitamin D. We continue to evolve with our medical knowledge and the importance of Vitamin D is new information.

Saturday, September 5, 2009

Study Shows Thin Thighs Increase Heart Disease

Finally, a study that many women can like. The British Medical Journal published a study out of Denmark that looked at the association between thigh circumference and the incident of cardiovascular disease and mortality. Why anyone would even think of thigh circumference being of importance is beyond me, but the Danes seem to think it was important. They found people with thin thighs had more risk of developing heart disease or premature death.

The study looked at 1436 men and 1380 women and examined them for height, weight, hip, thigh and waist circumference. The results showed that small thigh circumference (below 60cm or 23 inches) was associated with more cardiovascular disease and mortality. They did not find the same association with waist size and the findings were independent of percentage body fat mass or obesity. Small thighs were a disadvantage to health and survival for both sexes.

Twenty three inches is not a very small thigh, and in fact, more than half of the men and women aged 35-65 have thigh circumferences below that size. Maybe it has to do with muscle mass (less exercise, less mass). I can't imagine any other reason this strange finding should occur.

I think this study will probably not hold up to analysis and further investigation. There are just too many variables and I don't think people with large thighs should feel they are immune to heart disease.

But the idea that, for once...the skinny models and actresses don't have the advantage is kind of heart warming.

Thursday, September 3, 2009

California HMOs Deny 1 in 5 Claims

Thank you California Nurses Association for doing the first analysis of how many claims California insurers reject and don't pay. The result is shocking. One insurer (PacifiCare) denies 39.6% of claims. Anthem Blue Cross, the state's largest for-profit health plan rejected 28% of all claims. These denials, after premiums have been paid for months and years, reflect what is wrong with our insurance industry. Sure, the majority of Americans have health insurance, but is this how it is supposed to operate?

The spokesman for the California Assn. of Health Plans says the claims are denied for legitimate reasons. It is hard for me to see how almost 40% of health claims could be not legitimate. Was the paperwork not filled out correctly? Did the patient not really have a broken arm that needed treatment? Did the person go to an emergency department that was not contracted with the insurer? The treatment was experimental? I am racking my brain to come up with the possible excuses for denial. Keep in mind these denials for payment are all after care was given.

The Department of Managed Care, which is supposed to oversee the HMO insurance industry in California was criticized for not publishing this information themselves, since the data came from their own records. I was amused by their reply;

"It is important to point out that a denied claim means that the patient received the medically necessary services, but the doctor or hospital was not paid for that care," said spokeswoman Lynne Randolph.

Now that makes me feel a lot better.

Tuesday, September 1, 2009

Prostate Cancer Overdiagnosis

One of the hardest things to explain to patients is the whole deal about overdiagnosis of prostate cancer in men. More than 1 million men in the U.S. have been diagnosed with and treated for prostate cancer since that test has been used. That would be good news, except for the fact that the "vast majority of these 1 million men did not benefit from early detection," according to a new study published in the Journal of the National Cancer Institute.

The bottom line is that screening for prostate cancer is of questionable benefit. Another 2009 study published in the New England J of Medicine, had the same findings...that screening for prostate cancer did not provide a mortality benefit. An elevated PSA is not specific for cancer and a significant number of men with PSA values under 4 have prostate cancer. It is not a very good test and tumors can be slow growing and of no health significance.

To add to the confusion, the American Urological Association (Society of Urologists) issued guidelines that PSA screening should begin in healthy men at age 40. Keep in mind that Urologists benefit greatly when men with elevated PSAs need imaging studies and biopsies. It is these invasive procedures that are considered "over treatment" in the other studies.

The US Preventive Services Task Force has concluded that the evidence is insufficient to make a recommendation for or against routine screening using PSA testing or digital rectal examinations. The US Preventive Services Task Force cites the current lack of evidence that early detection improves health outcomes and the potential harm that can result from treatment.

With these divergent opinions from major credible scientific organizations, you can see that this is very muddy water. Those of us who are in the trenches, taking care of patients, are left to try and explain the current science to men (impossible) and to make our best judgment about screening tests.

I do it, but I am less than comfortable with the results.

When to Use Urgent Care

We all know that Emergency Departments are over-crowded with long waits and exorbitant fees.  Free standing Urgent Care is a great solu...